Provider Demographics
NPI:1316233497
Name:MONTAGUE, DOMINIQUE (PA-C)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:MONTAGUE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 HIGHLAND AVE APT 110
Mailing Address - Street 2:
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-1503
Mailing Address - Country:US
Mailing Address - Phone:480-540-2916
Mailing Address - Fax:
Practice Address - Street 1:307 S EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-2739
Practice Address - Country:US
Practice Address - Phone:800-848-3721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical